- The nurse-client relationship is the foundation on which psychiatric nursing is established.
- The therapeutic interpersonal relationship is the process by which nurses provide care for clients in need of psychosocial intervention.
- Mental health providers need to know how to gain trust and gather information from the patient, the patient's family, friends and relevant social relations, and to involve them in an effective treatment plan.
- Therapeutic use of self is the instrument for delivery of care to clients in need of psychosocial intervention.
- Interpersonal communication techniques are the “tools” of psychosocial intervention.
THERAPEUTIC NURSE-CLIENT RELATIONSHIP
- Therapeutic relationships are goal- oriented and directed at learning and growth promotion.
Therapeutic Use of Self
- Definition - ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions.
- Nurses must possess self-awareness, self-understanding, and a philosophical belief about life, death, and the overall human condition for effective therapeutic use of self.
Requirements for Therapeutic Relationship
Phases of a Therapeutic Nurse-Client Relationship
- Pre-interaction phase
- Orientation/Introductory Period
- Interpersonal communication is a transaction between the sender and the receiver. Both persons
- In the transactional model, both participants perceive each other, listen to each other, and simultaneously engage in the process of creating meaning in a relationship, focusing on the patients issues and assisting them learn new coping skills.
- Both sender and receiver bring certain preexisting conditions to the exchange that influence the intended message and the way in which message is interpreted.
CONTEXT OF THERAPEUTIC COMMUNICATION
Values, attitudes, and beliefs.
- Example: attitudes of prejudice are expressed through negative stereotyping.
Culture or religion
- Cultural mores, norms, ideas, and customs provide the basis for ways of thinking.
- High-status persons often convey their high-power position with gestures of hands on hips, power
dressing, greater height, and
more distance when communicating
with individuals considered to be of
lower social status.
- Masculine and feminine
gestures influence messages conveyed in communication with others.
Age or developmental level
- Example: The influence of developmental level on communication is especially evident during adolescence, with words such as “cool,” “awesome,” and others.
- Territoriality, density, and distance are aspects of environment that communicate messages.
- Territoriality - the innate
tendency to own space
- Density - the number of people within a given environmental space
- Distance - the means by which various cultures use space to communicate
Proxemics: Use of Space
- Intimate distance - the closest
distance that individuals allow
between themselves and other
- Personal distance -the distance for
interactions that are personal in
nature, such as close conversation
- Social distanc - the distance
for conversation with strangers
- Public distance - the distance for speaking in
public or yelling to someone some distance away
Nonverbal Communication: Body Language
Components of nonverbal communication
- Physical appearance and dress
- Body movement and posture
- Facial expressions
- Eye behavior
- Vocal cues or paralanguage
THERAPEUTIC COMMUNICATION TECHNIQUES
- Using silence - allows client to take control of the discussion, if he or she so desires
- Accepting - conveys positive regard
- Giving recognition - acknowledging, indicating awareness
- Offering self - making oneself available
- Giving broad openings - allows client to select the topic
- Offering general leads - encourages client to continue
- Placing the event in time or sequence - clarifies the relationship of events in time
- Making observations - verbalizing what is observed or perceived
- Encouraging description of perceptions - asking client to verbalize what is being perceived
- Encouraging comparison - asking client to compare similarities and differences in ideas, experiences, or interpersonal relationships
- Restating - lets client know whether an expressed statement has or has not been understood
- Reflecting - directs questions or feelings back to client so that they may be recognized and accepted
- Focusing - taking notice of a single idea or even a single word
- Exploring - delving further into a subject, idea, experience, or relationship
- Seeking clarification and validation - striving to explain what is vague and searching for mutual understanding
- Presenting reality - clarifying misconceptions that client may be expressing
- Voicing doubt - expressing uncertainty as to the reality of client’s perception
- Verbalizing the implied - putting into words what client has only implied
- Attempting to translate words into feelings - putting into words the feelings the client has expressed only indirectly
- Formulating plan of action - striving to prevent anger or anxiety escalating to unmanageable level when stressor recurs
THERAPEUTIC COMMUNICATION AND PROBLEM-SOLVING
Goals are often achieved through use of the problem-solving model:
- Identify the client’s problem.
- Promote discussion of desired changes.
- Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively.
- Discuss alternative strategies for creating changes the client desires to make.
- Weigh benefits and consequences of each alternative.
- Help client select an alternative.
- Encourage client to implement the change.
- Provide positive feedback for client’s attempts to create change.
- Help client evaluate outcomes of the change and make modifications as required.
LISTENING TO THE PATIENT
- To listen actively is to be attentive to what client is saying, both verbally and nonverbally.
Several nonverbal behaviors have been designed to facilitate attentive listening.
- S – Sit squarely facing the client.
- O – Observe an open posture.
- L – Lean forward toward the client.
- E – Establish eye contact.
- R – Relax.
- Written reports of verbal interactions with clients
- A means for the nurse to analyze the content and pattern of interaction
- A learning tool for professional development
- How do I give a Patient Feedback
Feedback is useful when it
- is descriptive rather than evaluative and focused on the behavior rather than on the client
- is specific rather than general
- is directed toward behavior that the client has the capacity to modify
imparts information rather than offers advice.
Nontherapeutic Communication Techniques
- Giving reassurance - may discourage client from further expression of feelings if client believes the feelings will only be downplayed or ridiculed
- Rejecting - refusing to consider client’s ideas or behavior
- Approving or disapproving - implies that the nurse has the right to pass judgment on the “goodness” or “badness” of client’s behavior
- Agreeing or disagreeing - implies that the nurse has the right to pass judgment on whether client’s ideas or opinions are “right” or “wrong”
- Giving advice - implies that the nurse knows what is best for client and that client is incapable of any self-direction
- Probing - pushing for answers to issues the client does not wish to discuss causes client to feel used and valued only for what is shared with the nurse
- Defending - to defend what client has criticized implies that client has no right to express ideas, opinions, or feelings
- Requesting an explanation - asking “why” implies that client must defend his or her behavior or feelings
- Indicating the existence of an external source of power - encourages client to project blame for his or her thoughts or behaviors on others
- Belittling feelings expressed - causes client to feel insignificant or unimportant
- Making stereotyped comments, clichés, and trite expressions - these are meaningless in a nurse-client relationship
- Using denial - blocks discussion with client and avoids helping client identify and explore areas of difficulty
- Interpreting - results in the therapist’s telling client the meaning of his or her experience
- Introducing an unrelated topic - causes the nurse to take over the direction of the discussion
- Effective communication is the core skill in mental health care in primary care settings.
- Self-awareness and ability to collaborate with other health care providers are also skills that will facilitate accurate inquiry into the patient's true concerns and the context in which they occur.
- Epstein RM, Borrell F, Caterina M . Communication and mental health in primary care. In New Oxford Textbook of Psychiatry (Edrs. Gelder MG, López-Ibor JJ, Andreasen NC), Oxford University Press, 2000.